Provider Demographics
NPI:1447225669
Name:BORDELON, BROCK M (MD)
Entity Type:Individual
Prefix:DR
First Name:BROCK
Middle Name:M
Last Name:BORDELON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2222 N NEVADA AVE
Mailing Address - Street 2:SUITE 5017
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6831
Mailing Address - Country:US
Mailing Address - Phone:719-635-2501
Mailing Address - Fax:719-632-1062
Practice Address - Street 1:2222 N NEVADA AVE
Practice Address - Street 2:SUITE 5017
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6831
Practice Address - Country:US
Practice Address - Phone:719-635-2501
Practice Address - Fax:719-632-1062
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO33407208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01334077Medicaid
020027676OtherRAILROAD MEDICARE
4530815OtherAETNA PIN
COBRD1868OtherCOLORADO BLUE SHIELD
COBRD1868OtherCOLORADO BLUE SHIELD
COCD1868Medicare PIN